Annual Report 2021–2022

Chair's foreword

I am pleased to present the Child Death and Serious Injury Review Committee’s seventeenth Annual Report to Parliament.

In my first six months as Committee Chair, I have learnt that close review of the circumstances of a death can shine a light on the issues that should be addressed to strengthen the systems that keep children and young people safe and well. However, system change is not easy to achieve. The Committee continues to pursue as many avenues as possible to influence change that can contribute to better outcomes for children and young people.

Three issues of major importance have repeatedly come to my attention as the Committee reviews the circumstances of children’s deaths:

  • When the lives of children and young people are complex, service systems need to manage that complexity through collaborative effort and services that wrap around a child or young person and their family.
  • One-off interventions are not enough – children and young people need to be supported by systems with a long-term approach.
  • Children and young people need to be ‘seen and heard’ when decisions are made about them.

The COVID-19 pandemic has brought new challenges to the lives of children and young people. In what ways this might be reflected in the causes or circumstances of child deaths is yet to be completely revealed, but the sharp decrease in death rates in 2019 and 2020, and the notable increase in 2021, suggest it is likely there will be lessons to be learned.

South Australia is a small state and the number of child deaths is proportionately small. The Committee is supporting conversations between states and territories that will lead to the development of a national child death data collection. Such a collection will provide unique opportunities to fully explore the factors that attend and impact upon the death of children and young people.

Thank you to the Aboriginal leaders and thinkers who came together to co-design the Terms of Reference for the establishment of the Oversight and Advocacy Authority for Aboriginal Children and Young People – CDSIRC, and who will now take the first steps towards developing a framework for the review of Aboriginal child deaths. I know the work will be challenging but I believe it is essential to the work of the Committee and has the potential to make a substantial contribution to understanding and preventing Aboriginal child deaths.

I have been astounded by the amount of time and expertise members contribute to the Committee’s work. There is no other body in the state that undertakes the kind of multi-disciplinary review achieved by this Committee, across vulnerable populations and in relation to many different issues including suicide, transport crashes, sudden unexpected infant deaths and chronic illness. I thank each of the Committee members for the diligence, enquiry and care that they have brought to the Committee’s deliberations, especially noting the contribution of two out-going members – Ms Angela Davis and Ms Ann-Marie Hayes. I also thank the Committee’s accomplished and hard-working Secretariat, without which the work of the Committee would not be possible.

On behalf of the Committee, I extend my condolences to the families and friends who have experienced the death of a child, and to the communities and professionals who have helped to care for them.

Ms Jane Abbey SC

Child Death and Serious Injury Review Committee